Popular perceptions of tobacco products and patterns of use among male college students in India
Introduction
India is the third largest producer of tobacco in the world, and a country where tobacco is consumed in a wide variety of ways. Country-wide estimates of tobacco use suggest that tobacco prevalence is increasing in India. Also on the rise are tobacco-related diseases which presently account for one-half million deaths per year. By the year 2020, the annual number of tobacco-related deaths is projected to reach 1.5 million, accounting for approximately 13% of all deaths in the country (Kumar (2000a), Kumar (2000b)). One distinctive feature of tobacco-related morbidity in India is that the incidence of oral cancers caused by the chewing of tobacco products exceeds that of lung cancer and is one of the highest in the world. Oral cancer accounts for 30–40% of all diagnosed cancer cases in the country (Gupta, 1999).
Five of the main ways in which tobacco is consumed in South India, the site of the present study, are the smoking of cigarettes and bidi, and the chewing of pan, gutkha, and khaini. Cigarette production has increased steadily in India. In 2000–2001, 91,400 million sticks were produced and this number is expected to exceed 100,000 million sticks in 2001–2002 (Padmanabhan & Dikshit, 2001). The consumption of cigarettes is high in India with approximately 110 billion cigarettes sold each year (the equivalent of US$2 billion in sales). Between 1990–95, per capita consumption of cigarettes in India increased, a distinction it shares with only two other countries: China and Indonesia (The World Bank, 1999). During this time, the real price of cigarettes decreased by 45%. Even though India's cigarette tax is low by international standards, it contributes 90% of the government's revenue from tobacco (Bose, Bamzai, Mohan, & Chawla, 2001). Importantly, more than 65% of cigarette sales in India are for single sticks. The cost of a single cigarette ranges from US$0.04–0.06, depending on the brand. Although relatively inexpensive, cigarettes are eight to ten times more expensive than bidis. Unlike bidis, cigarettes are a highly advertised product in which themes of sophistication, romance, sports, and adventure are prominent. As a result, cigarettes have come to be associated with higher socioeconomic status and sophisticated lifestyles (Gupta et al., 1992). Cigarettes are distributed by a highly sophisticated marketing network which reaches even the most remote village shops.
Bidis are small cigarettes consisting of indigenously grown tobacco wrapped in a temburni leaf (Diospyros melanoxylon). They are hand-rolled as a cottage industry in India and sold in packets of 20–30 bidis. Although smaller than cigarettes, smoking bidis yields more than three times as much carbon monoxide and more than five times as much nicotine and tar as cigarettes (Jayant & Pakhale, 1989). Since the leaf is not porous, the bidi smoker has to inhale often and deeply to keep it lit (Gupta & Ball, 1990). In fact, a bidi smoker must take three to four times as many puffs as one does with a cigarette. The topography of bidi use, in addition to the contents of bidis, make them particularly harmful for health. They are the most popular tobacco product on the Indian market, particularly among agricultural laborers, and account for 55% of tobacco consumption in India. Bidis do not carry warning labels.
Oral use of smokeless tobacco is very common in India, and is both prepared by the user as well as available prepackaged. Pan, also known as betel quid, is a product hand rolled at the time of consumption. It consists of one of several varieties of betel leaf (Piper betle) in which areca nut (Areca catechu) and slaked lime are added, often along with tobacco. Condiments and sweetening agents may also be added. Pan chewing is a widespread cultural practice engaged in at important events such as marriages, funerals, and ritual performances. In the study field site, it was common for guests to be offered a plate containing betel leaves, areca nut and tobacco shortly after entering a home.
Gutkha, a prepackaged mixture of chewing tobacco, areca nut, lime, and aromatic spices, is sold in small packets. It is widely available in small roadside shops and costs between Rs 1.50 and Rs. 4 (between US$0.04–0.11 per packet), depending on the size of the packet. Gutkha is a relatively recent product in the region of South India where the study was conducted. About 10 years ago, the product was introduced through tobacco distributors located in Mangalore, the district capital. Rapidly distributed through a network of agents, it has become popular among youth, manual laborers who find this product fast and convenient to use, and people in urban areas who wish to chew but do not want to stain their mouth red, which occurs as a result of chewing betel quid. Gutkha has been a source of public health concern because regular chewers of this product have been observed to experience a rapid progression to pre-cancerous oral lesions and submucuous fibrosis (Halarnkar, 1997). Khaini, a packaged chewing preparation containing tobacco flakes, slaked lime, and aromatic spices is cheaper than gutkha, costing only Rs. 1.50 (US$0.04) per packet. Khaini is stronger and harsher than gutkha and one packet contains sufficient tobacco for three chews.
Prevalence data on tobacco consumption in India is limited. It is estimated that 52–70% of males and 3–38% of females currently use tobacco in some form in different areas of India (Aghi, 1992; Bhonsle, Murti, & Gupta, 1992; Gupta, 1996; Gupta & Ball, 1990). In general, Indian men smoke as well as chew tobacco, whereas the vast majority of women who use tobacco are chewers (usually hand-rolled pan with tobacco). Cigarette smoking among women is not widely acceptable in India, although it is gaining some popularity among the elite in urban centers such as Mumbai and Delhi (Aghi, Asma, Yeong, & Vaithinathan, 2001; Kaufman & Nichter, 2001).
A review of the literature reveals that survey findings on tobacco use among adults often fail to differentiate which product is consumed and at what levels of consumption. Few studies provide information on patterns of use and age of initiation for tobacco; in addition, age groups used in estimating prevalence are broad, making age-specific examination of tobacco use over time difficult. Observational data suggest that patterns of tobacco use vary widely by age group, region (urban vs. rural), gender, and socioeconomic status.
The results of adult and several youth-based studies may be highlighted. A large cross-sectional study of adults in Mumbai found that 69% of males were tobacco users, with 24% using cigarettes or bidi (Gupta, 1996). Approximately one-half of those who smoked were cigarette smokers and one-half were bidi smokers. The median age of initiation for smokers was 21.5 years and the median number of cigarettes smoked per day was 5. Cigarette smoking showed a strong positive association with education, an association the author links to sophisticated images of cigarette smoking promoted through advertising (Gupta, 1996).
A survey conducted among 1600 Mumbai youth, aged 14–15, found that 13% of boys and 1% of girls had used tobacco (Jayant, Notani, Gulati, & Gadre, 1991). Tobacco use was significantly more prevalent (23%) among students in private English-medium schools (a proxy for social class) when compared to those studying in regional-language public schools (Jayant et al., 1991). Among youth who had used a tobacco product, more than 85% had smoked cigarettes. The popularity of cigarettes among students in English-medium secondary schools lends credence to Gupta's findings about cigarette use among the educated. Less than 5% of these youth had experimented with any form of smokeless tobacco. A smaller study among 600 students (aged 15–22) in rural and urban Andhra Pradesh found that 12% of male students were occasional or daily cigarette smokers, and only one female smoked (Gavarasana, Doddi, Prasad, Allam, & Murthy, 1991). Among males who smoked, 60% were occasional smokers, and 40% defined themselves as regular smokers. The study did not report on use of smokeless tobacco products (Gavarasana et al., 1991). A study of college and school-aged students in Haryana found that 14% of males and 2% of females reported ever smoking (Kapoor, Anand, & Kumar, 1995). Results of the India Global Youth Tobacco Survey, sponsored by the Centers for Disease Control and Prevention (2000), reveal that among youth in standards 8–10 (aged 13–15) in the South Indian state of Tamil Nadu, only 6% of males and 4% of females report that they had ever smoked cigarettes.
What existing studies fail to provide is a sense of how tobacco consumption is changing among youth given the introduction of new products on the market (e.g., gutkha), changes in the modal age of initiation, patterns of consumption, perceived tobacco consumption among youth, and social factors influencing tobacco use. The researchers designed the present ethnographic and survey-based study of youth tobacco consumption bearing these issues in mind.
The study was conducted in Dakshina Kannaa District, Karnataka, where two of the authors (Nichter and Nichter) have conducted long-term ethnographic research (1974-present) on a range of health-related issues (Nichter & Nichter, 1996). These authors have fluency in the local language, Kannaa. Eleven key questions guided the study:
- 1.
Among male college students in the district, what tobacco products are most commonly being consumed?
- 2.
What factors account for the popularity and non-popularity of various products?
- 3.
At what age are students initiating tobacco use?
- 4.
Given the multitude of tobacco products available in India, can some products be characterized as starter products? Do some students use multiple products, and if so, do they progress from one to another?
- 5.
What are the typical patterns of use among male college students, and do these vary in regard to school culture?
- 6.
What are the perceived benefits of using various tobacco products?
- 7.
Which tobacco products are considered most harmful and most addictive by youth and why?
- 8.
What are the most important influences on tobacco use among college youth? To what extent do peers and family members serve as influences on youth smoking behavior?
- 9.
What do youth think about tobacco advertisements and how do they affect their smoking behavior?
- 10.
What are youths’ perceptions of rates of tobacco use and how close are they to existing patterns?
- 11.
Do youth view tobacco use as a problem in India?
The study was conducted from January to April 1998 in the coastal Karnataka district known as Dakshina (South) Kannaa. Unlike other regions of India, the district has a very high literacy rate of 77% (68% female; 85% male), with 32,000 students enrolled in colleges. The district has more private colleges than any other district in Karnataka, and is known around India as a center for higher education. Within the district, there is a wide range of public and private colleges which vary in the quality and medium of education, the courses offered, and their physical layout. While students from a range of socioeconomic classes attend these colleges, the course of study which students are enrolled in serves as a fair proxy for social class. That is, those students who come from wealthier families and have attended private English-medium schools and after-school tutorials tend to test (or buy) into more competitive and prestigious educational programs, such as medicine, engineering, and law.
For the purposes of this study, we chose a sample of eleven colleges reflecting the variability of these institutions in the region. College principals from Kannaa- and English-medium private and public schools and from technical and professional colleges were approached. All of the college principals who were approached agreed to participate. Of the 11 colleges surveyed, 2 were private Kannaa-medium, 3 were government Kannaa-medium (including one polytechnic), 3 were private English-medium (2 of which were Christian colleges), and 3 were English-medium professional colleges (medicine, engineering, and law). Seven of the colleges selected were located in the city of Mangalore, the district capital, and four were in towns about an hour and a half from the city.
Given previous findings of a low prevalence of smoking among school- and college-aged women in India and the limited resources available for the present study, the researchers decided to focus the survey component of their research solely on college-aged males. Although all the colleges surveyed were coeducational, the researchers chose not to conduct the survey among young women because preliminary ethnographic research in the region had revealed that the prevalence of tobacco use among college-aged females was extremely low, a finding that has been corroborated in research studies around India. The researchers recognized that the survey instrument developed for male students would have been inappropriate for female college students. Thus, it was decided that the focus for the quantitative component of the project would be on those students who were most likely to be using tobacco products. To understand young women's perceptions of smoking, several focus groups were conducted with female college students.
Section snippets
Methods
Two months of focused ethnographic fieldwork were conducted to enable the researchers to gather data on how tobacco use was discussed by college students and to facilitate the development of the survey instrument. During the ethnographic component, twenty-five key informant interviews were conducted with male students attending colleges to be included in the survey. A semi-structured interview guide was developed based on two of the researchers’ (Nichter and Nichter) previous ethnographic
Participants
The study sample consisted of 1587 male college students ranging in age from 16 to 23 years (mean age, 19.53 years old). The demographic charactersitics of respondents are summarized in Table 1. Sixty percent of respondents completed the survey in English, and 40% completed it in Kannaa, generally reflecting the language of instruction at the college.
Prevalence and frequency of tobacco use
In response to the question “Have you ever tried any tobacco products?” 45% (n=716) of informants responded “yes”, and 55% (n=871) responded
Discussion
This paper moves beyond previous studies of adolescent tobacco use in India to more closely examine prevalence, patterns of tobacco consumption, and social factors influencing tobacco use. Survey findings and observational data confirm that among college students, cigarettes are the most popular form of tobacco consumption. Thirty-six percent of students (n=1587) had ever tried cigarettes and 18% had ever tried gutkha. Only 10% had tried bidis, 6% had tried pan, and 5% had tried khaini. Daily
Acknowledgements
This research was supported by a grant to Mimi Nichter from the American Institute of Indian Studies, University of Chicago, and by a grant to Mark Nichter from the Rockefeller Foundation.
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